What are the treatment options for Meniere's disease?

Treatment Options for Meniere's Disease

The treatment of Meniere's disease should follow a stepwise approach, beginning with lifestyle modifications and medical therapy, progressing to more invasive interventions only when conservative measures fail to control symptoms.

First-Line Treatment: Lifestyle Modifications and Dietary Changes

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation 1
• Limit alcohol consumption as it can trigger vertigo attacks in susceptible patients 1
• Reduce caffeine intake which may act as a symptom trigger 1
• Identify and manage allergies, which may contribute to symptoms in up to 30% of patients 1
• Implement stress management techniques including relaxation exercises, regular physical activity, and adequate sleep 1
• Maintain a symptom diary to identify personal triggers 1

Acute Attack Management

• Offer a limited course of vestibular suppressants ONLY during acute vertigo attacks 2
• Use antihistamines such as meclizine or dimenhidrinato for symptomatic relief 1
• Consider short-term benzodiazepines to manage associated anxiety, with caution due to dependency risk 1
• Avoid vestibular rehabilitation during acute attacks as it is not effective in this setting 2

Maintenance Therapy

• Diuretics may be offered to reduce endolymphatic fluid volume 2, 1
• Betahistine may be offered as maintenance therapy to increase inner ear vasodilation and potentially reduce attack frequency 2, 3
• Patient education about the natural history, symptom control measures, and treatment options is essential 2

Second-Line Treatment: Intratympanic Therapies

• Intratympanic steroids may be offered to patients with active Meniere's disease not responsive to conservative treatment 2, 1
• Intratympanic gentamicin is an option for persistent vertigo, but carries a higher risk of hearing loss 1, 4
• Benefits of intratympanic therapies include improved vertigo control, better quality of life, and faster return to work 2
• Risks include potential hearing loss, tympanic membrane perforation, and persistent imbalance 2

Third-Line Treatment: Surgical Options

• For patients with preserved hearing, endolymphatic sac surgery may be considered 3
• For patients with poor hearing or when other treatments fail, more destructive options include:
  • Labyrinthectomy (with complete hearing loss in the affected ear) 3
  • Vestibular nerve section (when hearing preservation is desired) 3

Rehabilitation for Chronic Symptoms

• Vestibular rehabilitation should be offered for chronic imbalance between attacks and following ablative procedures 2, 5
• Vestibular therapy has been shown to improve symptom control, reduce fall risk, and enhance quality of life 2
• Vestibular rehabilitation is NOT recommended during acute vertigo attacks 2

Treatments NOT Recommended

• Positive pressure therapy (Meniett device) is not recommended based on systematic reviews showing ineffectiveness 2, 1

Follow-Up and Monitoring

• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after treatment 2
• Monitor changes in quality of life to assess treatment effectiveness 2
• Adjust treatment intensity based on symptom control 2

Common Pitfalls and Caveats

• No definitive cure exists for Meniere's disease 1
• Scientific evidence for many interventions, especially dietary modifications, is limited 1
• Consider comorbidities that may contraindicate certain medications (renal disease, cardiac disease, asthma) 1
• Avoid prolonged use of vestibular suppressants as they may impair central compensation 2
• Be cautious with long-term benzodiazepine use due to dependency risk 1
• Consider the risk of bilateral disease development when recommending ablative procedures 2